1417374869 NPI number — NORTHEAST GEORGIA WELLNESS ASSOCIATES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417374869 NPI number — NORTHEAST GEORGIA WELLNESS ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST GEORGIA WELLNESS ASSOCIATES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417374869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 451
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTERVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30683-0451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-296-1572
Provider Business Mailing Address Fax Number:
888-884-9828

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1197 CEDAR SHOALS DRIVE #103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-296-1572
Provider Business Practice Location Address Fax Number:
888-884-9828
Provider Enumeration Date:
03/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BIGNELL
Authorized Official First Name:
WHITNEY
Authorized Official Middle Name:
ELAINE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
706-296-1572

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  LD003881 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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